NCM 109 – ABNORMAL OB

With Maam Glorimae S. Rizabal

3/23/2023

HIGH RISK PREGNANCY

 BLEEDING DURING PREGNANCY

 Deviation from the normal pregnancy
 SHOCK
 Signs occur if 10% of blood volume or 2
units of blood is lost
 Fetal distress- 25 % of blood volume is lost
 Important to know the baseline BP for
pregnant women.

shock 2’HYPOVOLEMIA

• Blood loss------ decreased intravascular

volume------- decreased venous return,
decreased cardiac output, and lowered
BP----- body compensating ( increase HR, to
circulate the decreased volume faster,
vasoconstriction of peripheral vessels (to
save blood for vital organs), increased RR
and feeling of apprehension at body
changes also occur------cold clammy skin,
decreased uterine perfusion, decreased
BP------reduced renal, uterine and brain
CONDITIONS ASSOCIATED WITH FIRST TRIMESTER
perfusion-----lethargy, coma, decreased
BLEEDING
renal output-----renal failure----maternal
and fetal death 2 MOST COMMON CAUSE ARE:
 SPONTANEOUS MISCARRIAGE
 ECTOPIC PREGNANCY

SPONTANEOUS MISCARRIAGE/S. ABORTION

• Interruption of pregnancy before a fetus is

viable (able to survive outside uterus if born
at that time).
• Viable Fetus: fetus more than 20 to 24
weeks of gestation or one that weighs at
least 500 grams.
• A fetus born before this point is considered
a premature or immature birth.

• Elective abortion- planned medical

termination of a pregnancy.
• Miscarriage- interruption occurs
spontaneously.
CAUSES OF SPONTANEOUS MISCARRIAGE  Blood for HCG may be drawn at the start of
the bleeding and again 48 hours (if placenta
1.Abnormal fetal formation
is intact-level in the blood stream should
teratogenic factors or chromosomal double in this time)
aberration*  Avoid strenuous activities for 24 to 48 hours
50-80% aborted early have structural (live fetus and presumed placental bleeding)
abnormalities  CBR is usually not indicated- may stop
vaginal bleeding because blood is poling
2. Immunologic factors vaginally but when does ambulate again,
rejection of the embryo through immune bleeding recur.
response  Spotting stops within 24 to 48 hours after
reducing activity- gradually resumes
3. Implantation abnormalities activities.
 Coitus is restricted for 2 weeks after
4. Corpus luteum fails to produce enough
bleeding episodes to prevent infection and
progesterone to maintain deciduas basalis
avoid bleeding.
(progesterone therapy)
IMMINENT (INEVITABLE) MISCARRIAGE
5. Infection
• miscarriage becomes imminent (inevitable)
rubella, syphilis, poliomyelitis,
miscarriage if uterine contraction and
cytomegalovirus and toxoplasmosis- crosses
cervical dilatation occur. With cervical
placenta causing fetal death.
dilatation, the loss of product of conception
UTI-increases incidence
cannot be halted.
Infection • Should save any tissue fragments to be
examined.
 fetus fails to grow • If no FHR are detected and sonogram
 estrogen and progesterone production in reveals empty uterus or non viable fetus-
placenta falls - endometrial sloughing- may perform vacuum extraction (dilatation
prostaglandin released- leading to uterine and evacuation, D and E)- to ensure all
contractions and cervical dilatation- products of conception are removed.
expulsion of products of pregnancy.
 Ingestion of teratogenic drugs-Isotretinoin
(accutane)- if taken early in pregnancy can
lead to miscarriage or fetal abnormality.
 Ingestion of alcohol- early pregnancy loss

VAGINAL SPOTTING-presenting symptoms

• 1st indication- inform health provider

• History
• Ensure that woman did not self abort
COMPLETE MISCARRIAGE
THREATENED MISCARRIAGE
 Entire products of conception (fetus,
 Manifested by vaginal bleeding, initially
membranes and placenta) are expelled
beginning a scant bleeding and usually
spontaneously without any assistance.
bright red
• Bleeding slows within 2 hour and ceases
 Slight cramping but no cervical dilatation on
within few days.
vaginal examination
 Assess for fetal heart sounds and sonogram
INCOMPLETE MISCARRIAGE within 2 weeks. DIC – a coagulation defect
may develop if the dead (possibly toxic)
• Part of the conceptus ( usually fetus) is
fetus remains too long in the utero.
expelled but membrane or placenta is
retained in the uterus.
DIC – a coagulation defect may develop if
• Danger of maternal hemorrhage as long as
the dead (possibly toxic) fetus remains too
part of the conceptus is retained in the
long in the utero.
uterus (cannot contract effectively)
Woman needs support and counseling.
• Dilation and curettage ( D and C) or suction
curettage to evacuate the remainder of
pregnancy from uterus.
• Be certain that the woman knows that
pregnancy is already lost and procedure is
done to protect her from bleeding and
infection and not to end the pregnancy.

RECURRENT PREGNANCY LOSS

(PAST) 3 spontaneous miscarriage that

occured at the same gestational age are
MISSED MISCARRIAGE called HABITUAL ABORTERS.
(TODAY) RECURRENT PREGNANCY LOSS is
Referred to as EARLY PREGNANCY FAILURE-
used to describe this miscarriage pattern.
fetus dies in the utero but is not expelled.
Occur in about 1% of woman who want to
Maybe misleading- “missed”
be pregnant.
No increase size in the fundal height or no
FH sounds heard during pre natal CAUSES:
examination.
May have symptoms of threatened o DEFECTIVE SPERMATOZOA OR OVA
miscarriage (painless vaginal bleeding) or no
 Endocrine factors, poor thyroid function,
prior clinical symptoms.
luteal phase defect
Sonogram to establish fetus is dead. Embryo
 Deviations of uterus, septate or bicornuate
died 4 to 6 weeks before onset of
uterus
miscarriage symptoms or failure of growth
 Infection
was noted.
 Autoimmune disorders: lupus
D and E will be done.
anticoagulant/antiphospholipid antibodies
If pregnancy is over 14 weeks, labor may be
induced by prostaglandins suppository or
misoprostol (Cytotec)* to dilate the cervix
followed by oxytocin stimulation or
administration of mifepristone.
If pregnancy is not actively terminated,
miscarriage usually occurs spontaneously
COMPLICATIONS OF MISCARRIAGE Assessment and treatment:

1. Hemorrhage  CBC, electrolytes, serum creatinine, blood

type and cross match, cervical, vaginal and
 DIC urine culture.
 Monitor vs- hypovolemic shock  Foley catheter to monitor urine output
 Excessive vaginal bleeding- position woman hourly to assess kidney function
flat and massage uterine fundus to aid  IV fluids to restore fluid volume and for IV
contraction. meds.
 May need D and C or suction curettage to  High dose, broad spectrum antibiotic
empty uterus. therapy; combination of penicillin,
 BT to replace blood loss. gentamicin and clindamycin.
 Direct replacement of fibrinogen or another  Central venous pressure or pulmonary
clotting factor may be used to aid artery catheter- monitor left atrial filling and
coagulation. hemodynamic status
 Removal of infected and necrotic tissue- D
ONE SANITARY PAD PER HOUR IS EXCESSIVE!
and C or D and E
• Color changes: dark color to serous fluid  Tetanus toxoid SQ or tetanus immune
globulin IM- prophylaxis for tetanus
• Unusual odor or passing of large clots is
 May lead to infertility- uterine scarring or
abnormal
fibrotic scaring of the fallopian tubes.
• Oral meds: methylergonovine maleate  Counseling
(Methergine) to aid with contraction

2. Infection

 Danger signs: fever, abdominal pain,

tenderness and foul vaginal discharge.
 Fever: can be from decreased fluid intake
from miscarriage or systemic reaction.
( more than 38 c/ 104 F)
 Organism responsible for miscarriage:
Escherichia coli ( from rectum to vagina)-
wipe from front to back. Not to use
tampons- stasis of body fluid increase risk of
infection.
 Endometritis- infection of uterine lining  After miscarriage, because blood type of
conceptus is unknown, all women with RH
Septic Abortion negative blood should receive RH (D
 Abortion complicated by infection after antigen) immune globulin (RhIg)/RhogAM-
spontaneous miscarriage but more to prevent build up of antibodies in the
frequently on self abort/ illegal using non- event the conceptus is positive.
sterile instrument.
 Symptoms of fever, crampy abdominal pain,
uterus is tender to palpate. ECTOPIC PREGNANCY
 If left untreated can lead to toxic shock
syndrome, septicemia, kidney failure and • Implantation occurs outside uterine cavity.
death. • May occur on the surface of the ovary or in
the cervix.
 • The most common site in most 95%
Pregnancy is in FALLOPIAN TUBE, ( 80%
ampullar portion, 12% isthmus,
8%interstitial/ fimbrial)

 Increases incidence following in vitro

fertilization
 1 ectopic pregnancy have 10 to 20% chance
that subsequent pregnancy will also be
ectopic. (Salpingitis leves scarring bilateral)
 Congenital anomaly such as webbing
(fibrous bands) may also be bilateral.
 Oral contraceptives may reduce possibility
of ectopic pregnancy.

Fertilization ASSESSMENT
obstruction, adhesion, (chronic salpingitis, PID),  No unusual symptoms at the time of
congenital malformations, scars from tubal surgery, implantation
uterine tumor* pressing at the proximal end of tube,  Corpeus luteum continuous to function as if
zygote cannot travel the length of tube. It lodges at implantation were in the uterus.
the stricture site along the tube and implants there  No menstrual flow occurs
instead of in the uterus.
 May experience nausea and vomiting of
early pregnancy and HCG test will be
positive
 Approximately 2% of pregnancies are  At 6-12 weeks of pregnancy, zygote grows
ectopic large enough to rupture the slender
 2nd most frequent cause of bleeding early in fallopian tube or trophoblast cells break
pregnancy through narrow base- tearing and
 Occurs frequently in women who smokes. destruction of blood vessels in the tube
 Some evidence that IUD (Intra Uterine result.
Device) may slow transport of zygote which  If implantation is in the interstitial portion
cause increased incidence of tubal/ovarian of the tube (tube joins uterus) rupture can
implantation cause severe intraperitoneal bleeding.
 Incidence of tubal pregnancies is highest in  A tender mass is usually palpable in Douglas
the ampullar area (distal third) where blood cul de sac on vaginal examination.
vessels are smaller and profuse bleeding is
less likely but continued bleeding may result
in large amount of blood loss.

Therapeutic Management:

 Monitor amount of bleeding

 Assess vital signs
 Assess abdominal pain
 Experience sharp, stabbing pain in one of  Blood transfusion
her lower quadrant then rupture followed
by scant vaginal spotting. Surgery:
 With placental dislodgement progesterone  Salpingostomy
secretion stops and uterine deciduas begins  Administer Rhogam `for Rh (-) client
to slough, causing additional bleeding.
 If internal bleeding progresses to acute Abdominal Pregnancy
hemorrhage, a woman may experience
 Very rarely after ectopic pregnancy-
lightheadedness and rapid pulse, signs of
products of conceptions are expelled into
shock.
pelvic cavity with a minimum of bleeding.
 Leukocytosis maybe present (not from
 Placenta continuous to grow in fallopian
infection but from trauma) , temperature
tube spreading into uterus for better blood
usually normal.
supply or may escape in pelvic cavity and
 A transvaginal sonogram will demonstrate
may implant on organ such as intestine.
ruptured tube and blood collecting in the
Fetus will grow in the pelvic cavity.
peritoneum
 Fetal outline is easily palpable because it is
 Falling hcg or serum progesterone suggest
directly below abdominal wall not inside
pregnancy has ended.
uterus, `may experience painful fetal
 Gradually abdomen becomes rigid from
movements and abdominal cramping with
peritoneal irritation, umbilicus develop
fetal movements.
bluish tinge (cullen’s sign). May have
 Sudden lower quadrant pain earlier in
continuing extensive or dull vaginal and
pregnancy.
abdominal pain.
 A sonogram or MRI reveal fetus outside
 Movement of cervix on pelvic examination
uterus.
may cause excruciating pain.
 Danger: placenta will infiltrate and erode
 There may be pain in shoulders from blood
major blood vessels in the abdomen leading
in the peritoneal cavity causing irritation to
to hemorrhage.
the phrenic nerve.
  Gestational trophoblastic neoplasm that
arise from the chorion; characterized by the
proliferation and degeneration of the
chorionic or trophoblastic villi.

 If implanted on intestine, may erode so

deeply that it causes bowel perforation and
peritonitis.
 Fetus is at high risk - without good uterine
supply.
 A patient with Hydatidiform mole has a
 Survival rate is only 60% because of poor
positive signs of pregnancy but is not
nutrient supply (survived fetus has an
pregnant.
increased threat of fetal deformity or
 The #1 Complication is Choriocarcinoma
growth restriction from an inadequate
nutrient supply. • The Three H of H-mole
 At term, infant must be born by
laparotomy, placenta is often difficult to 1. Hyper - emesis gravidarum
remove after birth if it is implanted on 2. increase Hcg
abdominal organ such as intestine. It may 3. increase incidence for piH
be left in place and absorb spontaneously in
2-3 months.
 Follow up sonogram can be used to detect if
a woman can be treated with methotrexate
to help placenta absorb. (not effective)

SECOND TRIMESTER BLEEDING

 GESTATIONAL TROPHOBLASTIC DISEASE

(HYATIDIFORM MOLE)
 Screening or initial diagnostic test: Ultrasound

 Confirm- Ultrasonography
 Best major surgery: Cervical Cerclage,
McDonald Cerclage
 Possible surgical complication: Sterility,
rupture of the cervix premature delivery,
PREMATURE CERVICAL DILATATION pelvic bleeding
 Previously termed as incompetent cervix  Complication
 Painless premature dilatation of the cervix Hemorrhage,
(usually in the 16th to 20th week

Predisposing/Contributing Factors:

 Repeated dilatation of the cervix

 maternal DES ( Diethylstilbestrol) Exposure,
 Traumatic injuries to the cervix.
 Congenital anomaly
 Trauma to the cervix (surgery / birth)
 1. Uterine anomaly
 2. Habitual abortion
 3. Pre-term labor

Initial Signs

 Show (a pink-stained vaginal discharge)

 #1 Sign: Rupture of membranes and
discharge of amniotic fluid
 Late signs:
 Pressure or heaviness on the lower
abdomen.

Cardinal/Pathognomonic/major sign:
Surgery: Cervical Cerclage
 The cervix dilates painlessly in the second
trimester of pregnancy.  Shirodkar-Barter Technique ( internal os)
 Bloody show permanent suture: subsequent delivery by
 PROM C/S.
 Painless dilatation  Mc Donald Procedure ( external os)-suture
removed at term with vaginal delivery
 Birth of dead/non-viable fetus
 Usually 4-6 weeks after vaginal delivery is
 Administer tocolytic medications as ordered
the safe period for a patient to resume
Eg; Ritodrine, Hydrochloride (Yutopar):
sexual activity, when the episiotomy has
Terbutaline sulfate (Brethine):
healed and the lochia had stopped
 Magnesium Sulfate, Hydroxyzine
hydrochloride (Vistaril) is a common drug Best position before and after surgery
ordered to counteract the effect of
terbutaline (Brethine)  Side lying position
 Prone position
 Best side equipment • Marginal: only an edge of the placenta
 Suction extends to the internal os
 Limit activities • Low-lying placenta: implanted in the lower
 Observe for Ruptured BOW uterine segment but does not reach the os*
 Avoid vaginal douche
 Avoid coitus

Intervention

 Pre-op: Encourage patient to maintain bed

rest
 Post-op: Check for excessive vaginal
discharge and severe pain.
 Bed rest in trendelenburg position

CONDITIONS ASSOCIATED WITH THIRD

TRIMESTER BLEEDING
• Predisposing Factor Maternal age Parity
• Placental separation (no. Of pregnancy) Previous uterine surgery
 characterized by a sudden gush or trickle of • Increase in Congenital fetal anomalies
blood from the vagina
 further protrusion of the umbilical cord Assessment .
from the vagina • Painless Heavy bleeding
 a globular-shaped uterus, and an increase in • Soft, non tender, relaxed uterus w/ normal
fundal height. tone
• With cervical or vaginal laceration, the • Shock in proportion to observed blood loss
nurse notes a consistent flow of bright red • Signs of fetal distress usually not present
blood from the vagina. • Avoid coitus
• With postpartum hemorrhage, usually • Bleeding (30 weeks , differentiate upper
caused by uterine atony, the uterus isn't segment and cervix dilate)- placenta’s
globular. Uterine involution can't begin until inability to stretch
the placenta has been delivered • Abdominal examination -Prevents head
from engaging
• Rule out another cause of bleeding
(ruptured varices, cervical trauma)

PLACENTA PREVIA
Complication
• Improperly implanted placenta in the lower • Anemia
uterine segment near or over the internal • #1hemorrhage
cervical os • #2 shock,
• Total: the internal os is entirely covered by • renal failure
the placenta when cervix is fully dilated • #3 disseminated intravascular coagulation
• cerebral ischemia, maternal and fetal death
 Therapeutic Interventions
• Ultrasonography to confirm
• Depends on location of placenta, amount of
bleeding and status of the fetus.
• Home monitoring with repeated
ultrasounds may be possible with type I low
lying
• Control bleeding*bed rest, side lying
• Replace blood loss if excessive
• Cesarean birth if necessary
• Betamethasone is indicated to increase
fetal lung maturity.(less than 34 weeks)

 Apt/kleihauer –Betke test( test strip)-

detect whether the blood is fetal or
maternal in origin
 Never attempt pelvic or rectal exam-
hemorrhage
 IvF, large gauge catheter
 I and O
 Attached fetal monitor (FHT and  Premature separation of the placenta from
contractions) the uterine wall after the 20th week of
 Oxygen gestation and before the fetus is delivered
(FHT and contractions)  Placental abruption/ Premature separation
of placenta

Predisposing Factor
Potential fluid volume deficit
 Maternal age
• #1 Assessment - Monitor maternal vital  Parity
signs, FHR, and fetal activity  Previous abruptio placentae,Hypertension
• Assess bleeding (amount and quality) - Smoking
• Monitor and treat signs of shock - alcohol or cocaine abuse.
• Avoid vaginal examination if bleeding is  physical and mechanical factors such as
occurring over distension of the uterus that occurs
• Prepare for premature birth or cesarean with multiple gestation or polyhydranions
section  short umbilical cord, physical trauma*
• Administer IV fluids as ordered
• Administer iron supplements or blood
transfusion as ordered (maintain hematocrit
level)
• Prepare to administer Rh immune globulin

PREMATURE SEPARATION OF THE PLACENT Manifestation

(ABRUPTIO PLACENTAE)
 Painful vaginal bleeding
 Hypertonic to tetanic, enlarged uterus
 Board-like rigidity of abdomen and Cullen
Sign
 Abnormal/absent fetal heart tones
  Pallor moderate to severe and mother or fetus is in
 Cool, moist skin jeopardy.
 Bloody amniotic fluid • With mild separation without fetal distress
 Rising fundal height from blood trapped and in the presence of some cervical
behind the placenta effacement and dilatation: induction of labor
 Signs of shock may be attempted
 Manifestation of coagulopathy • Oxygen if necessary
 The abdomen will feel hard and boardlike • Maintenance of fluid and electrolytes
upon palpation as the blood penetrates the balance
uterine musculature and causes uterine
irritability- COUVELAIRE Risk for fluid volume deficit
UTERUS/UTEROPLACENTAL APOPLEXY
 Evident bleeding or not- shock may occur • #1 Assessment: Monitor and FHR
 DIC (fibrinogen level) • Assess for vaginal bleeding, abdominal pain,
and increase in fundal height
• Maintain bed rest
QUICK ASSESSMENT!
• Administer oxygen as prescribed
Draw 5 ml of blood, place in a clean and dry • Monitor and report any uterine activity
test tube, stand aside, untouched for 5 min. • Administer IV fluid as prescribed
If clot has not formed, suspect for • Monitor I & O
INTERFERENCE WITH BLOOD • Administer blood products as prescribed
COAGULATION. • Monitor blood studies
• Prepare for the delivery of the fetus as
quickly as possible
• May occur in the 1st or 2nd stage of labor * • Monitor for signs of disseminated
(monitor bleeding and pain) intravascular coagulation in the postpartum
period
Complication
• Hemorrhage, shock, renal failure, DIC,
maternal death, fetal death • Confirmatory Test
• Ultrasound detects retro-placental bleeding
(infection)
Therapeutic Interventions

The goal of management : control the

hemorrhage and deliver the fetus as soon
as possible.
 IVF *
 Fht, VS q 15 min.
 Fibrinogen det.
 Lateral position
 NO IE, PELVIC EXAM, ENEMA
• Replacement of blood loss. Disseminated Intravascular Coagulation
• With moderate or severe separation or (DIC)
maternal or fetal distress-Emergency
childbirth.  Predisposing /Contributing Factors
 Overwhelming infections particularly
• CS Delivery is the treatment of choice if the bacterial sepsis;
fetus is at term gestation or if the bleeding is  #1 abruption placenta;veclampsia;
 amniotic fluid embolism; IUFD(Intra-uterine topical hemostatic agents. Use tape
fetal death) or retention of dead fetus; cautiously.
burn; trauma; fractures; major surgery; fat
• 5. Maintain bed rest during bleeding
embolism; sock; hemolytic transfusion
episode.
reaction; malignancies particularly of lung,
colon, stomach, and pancreas • 6. If internal bleeding is suspected, assess
 Disseminated intravascular coagulation bowel sounds and abdominal girth.
(DIC) is a state of diffuse clotting in which
clotting factors are consumed. This leads to • 7. Evaluate fluid status and bleeding by
widespread bleeding. frequent measurement for vital signs,
 Platelet are decreased because they are central venous pressure, intake and output.
consumed by the process, coagulation
studies show no clot formation (and are
thus normal to prolonged); and fibrin plugs Screening or Initial Diagnostic Test
may clog the microvasculature diffusely,
oozing from injection sites, and presence of • PT; PTT; Platelet count
hematuria are signs associated with the Confirmative Test Decreased Fibrinogen level;
presence of DIC. increased fibrin split products; decreased anti-
 Swelling and pain in the calf of one leg are thrombin III level
more likely to be associated with
thrompophlebitis. • Beside Equipment ECG; CVP

Initial Sign • Best Drug Heparin inhibits clotting

components of DIC*
 Coolness and mottling of extremities;
 pain; • Nature of the Drug Anticoagulant
 dyspnea;
 abnormal bleeding

Late Sign

 Altered mental status;

 acute renal failure

Minimizing Bleeding

• 1. Institute Bleeding precautions

• 2. Monitor pad count/amount of saturation

during menses; administer or teach self-
administration of hormones to suppress
menstruation as prescribed.

• 3. Administer blood products as ordered.

Monitor for signs and symptoms of allergic
reactions, anaphylaxis, and volume
overload.

• 4. Avoid dislodging costs. Apply pressure to

sites of bleeding for at least 20 mins, use